Rare Alaska hearing probes causes for plane crashes

A packed audience took part in a nine-hour field hearing held by the National Transportation Safety Board in Anchorage on Aug. 17. The hearing, the first in the state since the Exxon Valdez oil spill, was called to examine the continued problem of crashes known as controlled flight into terrain that continue to occur with regularity in Alaska. (Photo/Elwood Brehmer/AJOC)

Why, in the technological age, are airworthy planes still being flown into the ground in Alaska?

That was the omnipresent question at the National Transportation Safety Board’s Aug. 17 hearing in Anchorage to further its investigation into the crash of Hageland Aviation Flight 3153 on Oct. 2, 2016, just outside of the Western Alaska village of Togiak.

The Hageland Cessna 208 Caravan was en route to Togiak from the nearby village of Quinhagak with a load of mail and one passenger when it crashed high on a mountainside about 12 miles from Togiak, according to representatives from the commuter airline. The controlled flight into terrain, or CFIT, crash killed the passenger and both pilots on impact.

While the number of CFIT accidents in Alaska has generally decreased over the last decade-plus, NTSB officials said leading up to the rare field hearing that they really shouldn’t be happening anymore at all.

Board member Earl Weener stated in a press release that the board traveled to Alaska because most of the witnesses the agency wanted to hear from are here.

However, the NTSB has investigated countless aviation accidents in the state over the years and the inquiry into the Togiak crash was the first investigative hearing the board has held outside of Washington, D.C., in nearly 20 years. It was the first in Alaska since the 1989 Exxon Valdez oil spill.

Weener, who ran the hearing, noted at its outset that the hearing was “strictly a fact-finding mission.”

“The board does not find fault or blame,” he said.

Federal Aviation Administration officials and Hageland leaders testifying under oath before the board stressed throughout the intense, nine-hour day of inquiry that two age-old Alaska themes are often at the root of CFIT crashes in the state: much of rural Alaska still lacks needed infrastructure to give pilots the information they need — in this case for weather reporting and communications —and the daring, “bush pilot culture” is still pervasive amongst the state’s aviators.

According to FAA data, the number of CFIT accidents in Alaska has gone from eight in 2002 and nine in 2003, to an average of four per year by 2016.

The number of CFIT accidents — fatal and nonfatal — involving commuter and flight service operators known as Part 135 has gone from five in 2002 to four in 2004 and has been one or two per year since 2006.

The overall average would be lower if not for a recent spike in incidents that prompted Alaska FAA Flight Standards Manager Clint Wease to issue a letter in May 2016 to Part 135 operations.

According to Wease at the time, CFIT accidents involving Part 135 aircraft in the year before the letter had led to 24 fatalities or serious injuries.

“Many of these CFIT accidents have occurred in aircraft with advanced avionics, which were capable of instrument flight and operated by experienced pilots,” Wease wrote.

His first of several recommendations in the letter was for pilots to operate under instrument flight rules, or IFR, whenever possible.

Hageland Operations Manager Luke Hickerson said in his testimony to the NTSB that about two-thirds of the airports the airline serves don’t have all of the equipment necessary to conduct IFR flights.

According to Hickerson, Hageland has about 7,600 possible “city pairs” in its flight network and its pilots perform roughly 150,000 takeoffs and landings per year on about 55,000 flights.

Erin Witt, Hageland’s chief pilot, estimated that up to 15 percent of the airports the company flies to have no communication capabilities at all.

Hageland serves the numerous villages in the Yukon-Kuskokwim region of the state on behalf of its larger sister airline Ravn Alaska. The communications challenges are often compounded by the fact that the area regularly has low cloud ceilings that are sometimes at less than 1,000 feet, Hageland pilots testified.

Flying an IFR route allows a pilot to fly through and above cloud cover, almost eliminating the risk of CFIT accidents.

“I would love to operate a fleet of IFR aircraft” and fly by instruments all of the time, Witt said.

The alternative is flying below the ceiling under visual flight rules, or flying VFR.

Lacking weather reporting from official equipment such as National Oceanic and Atmospheric Administration automated weather observing systems, or AWOS, common at larger airports, Hageland pilots regularly use FAA weather cameras and call trusted sources in the villages such as state Department of Transportation workers at the airports for current conditions before take-off and, when possible, during a flight, Hickerson said.

The FAA maintains a network of more than 230 weather cameras in Alaska at airports and high-risk points. While they are viewed by small commercial operators across the state, the cameras are geared towards general aviation and information they provide cannot be used as a formal weather report by a commercial pilot.

When questioned by NTSB investigators why a pilot would rely on unofficial weather information, Hickerson responded by saying the pilots are “going from nothing and making something.”

Hageland pilot Natoshia Burdick, who was the safety pilot on a flight about five minutes behind Flight 3153, noted in testimony that a pilot flying in the Yukon-Kuskokwim area is required to get near-immediate clearance from air traffic control in Bethel when requesting to fly IFR and the tower is not always reachable.

“It’s a whole lot easier with the infrastructure that’s out there to go VFR,” Burdick said.

Additionally, pilots on IFR-capable routes may still have to fly below the clouds because many of the village airports do not have de-icing equipment, according to Hickerson.

Flying through clouds and at higher altitudes greatly increases the likelihood that ice will form on the aircraft and when a plane that has flown through icing conditions it cannot take back off without being sprayed down with a glycol solution.

Hageland has developed its own small, portable de-icing sprayer that can be kept in the small aircraft it flies, but with only about five gallons of fluid its usefulness is limited, company representatives testified.

Hickerson said there are reasons CFITs were a serious problem in the Lower 48 up until about 40 years ago.

“I think the technology and infrastructure advancements that have been made in the continental U.S. need to be made here,” he told the NTSB.

Deputy NTSB Director of Aviation Safety John DeLisi said the agency has recommended mandating CFIT avoidance training for all Part 135 pilots — it isn’t currently — while also seeming to commiserate somewhat with the Hageland witnesses.

“It would be great to have that infrastructure and we’re going to do our job to make that point,” DeLisi said in response to Hickerson.

FAA Alaska Region Administrator Kerry Long, who has held the position for about three years, said in an interview that he believes he and his staff have made progress of late in getting key agency personnel from the Lower 48 to visit Alaska and recognize the challenges the aviation industry faces in the state.

Long said a pending report commissioned by the FAA from the RTCA — an aviation technology nonprofit —should highlight Alaska issues for decision-makers in Washington, D.C. He called the lack of weather and navigational infrastructure in parts of Alaska “a pressing issue.”

“We believe that we have developed approaches that have made people more interested in coming up here as well as providing the information in forms that people understand better and this particular RTCA report will fit in with the recommendations that get made to the agency as a whole,” Long said.

He noted the FAA’s funding has been flat for several years as a result of Congress repeatedly passing continuing budget resolutions, which challenges the agencies ability to install new equipment.

“We can ask for it; we can push for it; we can do everything we can but if we can’t deliver we have to try harder,” he added.

Alaska Air Carriers Association Executive Director Jane Dale wrote in an email that despite the facts that 82 percent of Alaska communities are only accessible by air and the FAA encourages Alaska carriers to fly IFR, the state lags in AWOS stations and working ground-based navigational equipment.

“Infrastructure supporting IFR and VFR flights in Alaska is and has been the association’s number one priority for years,” Dale wrote. “This includes improving the availability of weather information in rural Alaska, proactive investment in aviation infrastructure and maintaining the existing infrastructure.”

Flight 3153 crash

Despite the apparent consensus among industry and government regulators at the hearing that Alaska’s aviation infrastructure is insufficient; it does not explain the Togiak accident.

The Quinhagak-Togiak route is IFR capable.

Burdick, a pilot on the trailing Hageland flight that detoured around the mountain before being notified of the crash, said agents at the company’s Operations Control Center led by Hickerson recommended flying IFR that day, but the Flight 3153 pilot chose not to.

Little explains the crash of the flight that had a pilot-in-command to fly the Cessna and a safety pilot tasked with — as the title implies — being a redundant safety check.

Hageland’s right-seat safety pilots are trained to clearly and directly voice any concerns they have with weather conditions or decisions made by the pilot-in-command, the company’s NTSB witnesses testified.

Burdick said when news of the crash made its way to their plane, she and her pilot-in-command attempted to locate the crash site but the 2,500-foot mountain was obscured by clouds below the broader ceiling.

The NTSB may yet find a definitive reason for the Hageland tragedy, but Hickerson and FAA officials said audacious attitudes are still far too prevalent among Alaska pilots, creating a wholly unnecessary danger, particularly among commercial pilots.

Hageland’s operational control agents at the center in Palmer discuss the circumstances surrounding each flight with the pilot before approving, or releasing it, Hickerson said.

An operations manager is involved if any disagreement arises between the pilot and the agent. He emphasized that the operations center is completely removed from the business side of the company.

“There is not pressure on the OCC to ever release a flight,” he said.

The OCC has cancelled more than 3,500 flights since the start of 2016 and turned another 600-plus around due to deteriorating weather, according to Hageland leaders.

Culture shift

Hickerson stressed that “safe, legal, and best practice” is what drives Hageland Aviation.

“It’s a lot easier to write rules and regulations than it is to change hearts and minds and that’s what we’re trying to do right now,” Hickerson said.

He continued: “The idea of turning around 10 years ago was unheard of and shamed not only by other pilots buy by companies as well.”

Wease generally agreed in his testimony, saying a series of Hageland incidents in the 2012-13 timeframe pushed the FAA to uncover what he described as a “poor pilot culture,” that he believes has since been corrected.

The company CEO starts each ground school with a talk to prospective pilots highlighting Hageland’s safety culture, Hickerson said, to illustrate it is truly companywide.

He said the company looks for reckless behavior “in every aspect of pilots’ lives,” because risks don’t announce themselves.

“You’ve got to listen for the whispers in the system,” Hickerson said.

Dale, of the Alaska Air Carriers Association, said the industry group does not agree with the belief that there is still an unsafe pilot culture in the state. Alaska operators “work hard to ensure a culture of safety,” according to Dale.

She again cited a lack of needed equipment in some areas of the state, noting some of the current AWOS and navigational infrastructure is often out of service.

Witt said pilots applying to fly for Hageland are screened with questions related to their decision-making and risk tolerances and about 10 percent of applicants are denied solely on those answers.

To that, FAA Alaska Certificate Office Manager Deke Abbott, who spent most of his career in aviation Outside, said he was taken aback by the adventurous nature of many Alaska pilots.

“We push the airplanes to get where we’re going,” Abbott said to the board, adding that when a pilot makes a decision, the consequences of that decision are ultimately solely the pilot’s responsibility.